School Suicide Prevention, Intervention and Postvention

1. School Suicide Prevention,Intervention and Postvention • LaShante Smith, CSUS graduate student, • Crystal Courtright, CSUS graduate student, • Stephen E. Brock, PhD, NCSP, LEP • California State University, Sacramento • brock@csus.edu 1

2. Presentation Outline • Introduction • Suicide Statistics • Primary Prevention of Suicide • Secondary Prevention of Suicide • General Staff Procedures • Risk Assessment and Referral Protocol • Suicide Postvention

3. National Youth Suicide Statistics • Fifth leading cause of death among 5-14 year olds in 2009 (N = 266; 0.7:100,000). • Third leading cause in the 10-14 age group, N = 259). • Third leading cause of death among 15-24 year olds in 2009 (N = 4,371; 10.1:100,000). Source: Kochanek, K. D., et al. (2011, March). Deaths: Preliminary data for 2009. National Vital Statistics Report, 59(4), 1-51. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_04.pdf 3

4. National Youth Suicide Statistics • 2011 YRBS1 • 15.8% of high school students reported having seriously considered suicide. • 12.8% reported having made a suicide plan. • 7.8% of high school students reported having attempted suicide. • 2.4% indicated that the attempt required medical attention. • 100 to 200 attempts for each completed youth suicide. • vs. 4 attempts for each completed suicide among the elderly.2 1Eaton, D. K. et al. (2012, June). Youth Risk Behavior Surveillance — United States, 2011. Morbidity and Mortality Weekly Report, 61(SS-4), 1-162. Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf 2McIntosh, J. L. (2011, October). USA suicide: 2008 final data. Washington, DC: American Association of Suicideology. Retrieved from http://www.suicidology.org/c/document_library/get_file?folderId=228&name=DLFE-392.pdf 4

5. Other Suicide Facts: All Age Groups • Total number of deaths (N = 36,909; 12.02:100,000) • 10th leading cause of death • Highest rate in 15 years. • More men die by suicide • 3.72 male suicides (N = 29,089) foreach females suicide (N = 7,820) Source: CDC. (2011). http://webappa.cdc.gov/cgi-bin/broker.exe 5

6. Total US Suicide Rate (1981-2009) Suicide Rate (per 100, 000) Source: CDC (2011) 6

7. Other Suicide Facts: All Age Groups • 50.6% of suicides are by firearms.1 • Suicide by firearms rate = 6.0:100,000 • N = 18,223 • Highest suicide rate is among white men over 85 (48.77:100,000 vs 11.82:100,000 among white male adolescent 15-19).2 • However the 2nd highest rate is among American Indian/Alaskan Native 20-24 year-old males (38.9:100,000). 1McIntosh, J. L. (2011, October). USA suicide: 2008 final data. Washington, DC: American Association of Suicideology. Retrieved from http://www.suicidology.org/c/document_library/get_file?folderId=228&name=DLFE-392.pdf 2Nantional Center for Injury Prevention and Control. (2011, December). WISQARS Injury Mortality Reports, 1999-2007. Atlanta, GA: Centers for Disease Control and Prevention. Retrieved from http://webappa.cdc.gov/sasweb/ncipc/mortrate10_sy.html 7

8. Suicide Rates by State (2009 Final Data) • Rank State (2008 rank) # Crude Rate • Montana 219 22.46 • Alaska 143 20.47 • Wyoming 111 20.39 • Idaho 304 19.67 • Nevada 505 19.11 • Colorado 941 18.73 • New Mexico 376 18.71 • Oregon 644 16.83 • Utah 449 16.12 • Arizona 1,060 16.07 • 42. California 3,823 10.30 • National Total 36,909 12.02 Source: CDC (2011) 8

9. US Suicide Rates by Age & Gender (2009 data) Suicide Rate (per 100, 000) Source: CDC (2011) 9

10. Youth Risk Behavior Survey - 2011 • During the 12 months before the survey, what percentage of students engaged in a variety of risky behaviors 10

11. High School Students who Felt “sad or hopeless” Percent Youth Risk Behavior Survey (2012) 11

12. High School Students who “seriously considered attempting suicide” Percent Youth Risk Behavior Survey (2012) 12

13. High School Students who “made a plan about how they would attempt suicide” Percent Youth Risk Behavior Survey (2012) 13

14. High School Students who “attempted suicide one or more times” Percent Youth Risk Behavior Survey (2012) 14

15. High School Students who “made a suicide attempt that … had to be treated by a doctor or nurse” Percent Youth Risk Behavior Survey (2012) 15

16. High School Students who Display Suicidal Behaviors Percent 16 Youth Risk Behavior Survey (2012)

17. Presentation Outline • Introduction • Suicide Statistics • Primary Prevention of Suicide • Preventing Suicidal Ideation and Behavior • Secondary Prevention of Suicide • General Staff Procedures • Risk Assessment and Referral Protocol • Suicide Postvention

18. What is the School Psychologist’s role in preventing suicide in schools? • School provides ideal opportunities for quality suicideprevention messages. • We are leaders in the school in developing a comprehensive crisis management system KING, K. A., STRUNK, C. M., & SORTER, M. T. (2011). Preliminary Effectiveness of Surviving the Teens® Suicide Prevention and Depression Awareness Program on Adolescents' Suicidality and Self-Efficacy in Performing Help-Seeking Behaviors. Journal Of School Health, 81(9) 18

19. Primary Prevention: Policy • It is the policy of the Governing Board that all staff members learn how to recognize students at risk, to identify warning signs of suicide, to take preventive precautions, and to report suicide threats to the appropriate parental and professional authorities. • Administration shall ensure that all staff members have been issued a copy of the District's suicide prevention policy and procedures. All staff members are responsible for knowing and acting upon them. 19

20. Primary Prevention:Gatekeeper Training • Training natural community caregivers • Advantages • Reduced risk of imitation • Expands community support systems • Research is limited but promising • Durable changes in attitudes, knowledge, intervention skills 20

21. Primary Prevention:Gatekeeper Training • A Specific Training Program: • Applied Suicide Intervention Skills Training • Author: Ramsay, Tanney, Tierney, & Lang • Publisher: LivingWorks Education, Inc • 1-403-209-0242 • http://www.livingworks.net/ • Since 1985, ASIST has been delivered to over one million caregivers in more than 10 countries. Today 5,000 registered trainers deliver ASIST around the world. ASIST is a recognized exemplary program (CDC, 1992). The program has been evaluated by more than 15 independent evaluations. • Training for Trainers is a five-day course that prepares local resource persons to be trainers of the ASIST workshop. Around the world, there is a network of 1000 active, registered trainers. 21

22. Primary Prevention:Curriculum • SOS: Depression Screening and Suicide Prevention • “The main teaching tool of the SOS program is a video that teaches students how to identify symptoms of depression and suicidality in themselves or their friends and encourages help-seeking. The program's primary objectives are to educate teens that depression is a treatable illness and to equip them to respond to a potential suicide in a friend or family member using the SOS technique. SOS is an action-oriented approach instructing students how to ACT (Acknowledge, Care and Tell) in the face of this mental health emergency.” • Evidenced based! 22

23. Primary Prevention:Screening • School-wide Screening • Very few false negatives • Many false positives • Requires second-stage evaluation • Limitations • Risk waxes and wanes • Principals’ view of acceptability • Requires effective referral procedures • Possible Tools • Suicidal Ideation Questionnaire (William Reynolds, Psychological Assessment Resources) • Columbia Teen Screen (Columbia University) • Beck Depression Inventory • SOS Depression Screening and Suicide Prevention 23

24. Middle & High School Age Youth Parent Consent and Participant Assent Screening Questionnaire Clinical Interview Parent Notification, Referral and Crisis Management Primary Prevention:Screening http://www.teenscreen.org/ Debriefing No Referral 24

25. Primary Prevention:Suicide Prevention & Crisis Hotlines • Rationale • Suicidal ideation is associated with crisis • Suicidal ideation is associated with ambivalence • Special training is requires to respond to “cries for help” • Likely benefit those who use them • Limitations • Limited research regarding effectiveness • Few youth use hotlines • Youth are less likely to be aware of hotlines • Highest risk youth are least likely to use 25

26. Primary Prevention:Suicide Prevention & Crisis Hotlines 26

27. Primary Prevention:Risk Factor Reduction • Restriction of Lethal Means • Media Education • Postvention • Skills Training 27

28. Primary Prevention: Risk Factor Reduction • Restriction of Lethal Means: Gun Control 28 Source: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5209a1.htm

29. Protective factors in preventing suicide • Family support and cohesion, including good communication. • Peer support and close social networks. • School and community connectedness. • Cultural or religious beliefs that discourage suicide and promote healthy living. • Adaptive coping and problem-solving skills, including conflict-resolution. • General life satisfaction, good self-esteem, sense of purpose. • Easy access to effective medical and mental health resources. Source: http://www.nasponline.org/resources/crisis_safety/suicideprevention.aspx 29

30. Presentation Outline • Introduction • Suicide Statistics • Primary Prevention of Suicide • Secondary Prevention of Suicide • Suicide Intervention • General Staff Procedures • Risk Assessment and Referral Protocol • Suicide Postvention

31. Duty to Warn • When a student is a danger to self or others there is a duty to warn. • Tarasoff v. Regents of the University of California

32. General Staff Procedures • Responding to a Threat of Suicide. • A student who has threatened suicide must becarefully observed at all times until a qualified staff member can conduct a risk assessment. • The following procedures are to be followed whenever a student directly or indirectly threatens to commit suicide.

33. General Staff Procedures • Stay with the student or designate another adult staff member to supervise the youth suspected to be at risk for suicide constantly until help arrives. • If the student has the means to carry out suicide on his or her person, determine if he or she will voluntarily relinquish it. • Do not force the student to do so or place yourself in danger. • If the student refuses to relinquish lethal means: • Protect yourself and your students. • Have the school office call 911. • Unless doing so would put yourself or your students in danger do not allow the student to leave the school.

34. General Staff Procedures • Do not agree to keep a student's suicidal intentions a secret. • Take the student to the prearranged room. • Notify the Designated Reporter (e.g., school psychologist or counselor). • Notify the School Principal (or other designated administrator). • Inform the youth that outside help has been called and describe what the next steps will be.

35. General Staff Procedures • Requires that school staff members have… • Knowledge of the risk factors the increase the odds of suicide. • Variables that should direct our attention. • Been trained to identify direct and indirect threats (or warning signs) that indicate the presence of suicide. • Variables that should direct our action.

36. General Staff Procedures • Risk Factors for Suicide • Biological • Reduced serotongenic activity • Situational • 40% have identifiable precipitants • A firearm in the home • By themselves are insufficient • Disciplinary crisis most common 36

37. General Staff Procedures • Risk Factors for Suicide • Psychopathology • Associated with 90% of suicides • Prior suicidal behavior the best predictor • Substance abuse increases vulnerability and can also act as a trigger • Familial • History • Stressor • Functioning 37

38. General Staff Procedures Risk Factors for Suicide • Divorced, separated, or single marital status • Early loss or separation from parents • Family history of suicide • Hallucinations • Homicide • Hopelessness • Hypochondriasis • Adolescence and late life • Bisexual or homosexual gender identity • Criminal behavior • Cultural sanctions for suicide • Delusions • Disposition of personal property 38

39. General Staff Procedures • Warning Signs for Suicide • Verbal • Most individuals give verbal clues that they have suicidal thoughts. • Clues include direct ("I have a plan to kill myself”) and indirect suicide threats (“I wish I could fall asleep and never wake up”). • Behavioral 39

40. General Staff Procedures • Verbal Warnings Signs of Suicide • “Everybody would be better off if I just weren’t around.” • “I’m not going to bug you much longer.” • “I hate my life. I hate everyone and everything.” • “I’m the cause of all of my family’s/friend’s troubles.” • “I wish I would just go to sleep and never wake up.” • “I’ve tried everything but nothing seems to help.” • “Nobody can help me.” • “I want to kill myself but I don’t have the guts.” • “I’m no good to anyone.” • “If my (father, mother, teacher) doesn’t leave me alone I’m going to kill myself.” • “Don’t buy me anything. I won’t be needing any (clothes, books).” 40

41. General Staff Procedures • Behavioral Warning Signs of Suicide • Writing of suicidal notes • Making final arrangements • Giving away prized possessions • Talking about death • Reading, writing, and/or art about death • Hopelessness or helplessness • Social Withdrawal and isolation • Lost involvement in interests & activities • Increased risk-taking • Heavy use of alcohol or drugs 41

42. General Staff Procedures • Behavioral Warning Signs of Suicide (cont.) • Abrupt changes in appearance • Sudden weight or appetite change • Sudden changes in personality or attitude • Inability to concentrate/think rationally • Sudden unexpected happiness • Sleeplessness or sleepiness • Increased irritability or crying easily • Low self esteem 42

43. General Staff Procedures • Behavioral Warning Signs of Suicide (cont.) • Dwindling academic performance • Abrupt changes in attendance • Failure to complete assignments • Lack of interest and withdrawal • Changed relationships • Despairing attitude 43

44. Presentation Outline • Introduction • Suicide Statistics • Primary Prevention of Suicide • Secondary Prevention of Suicide • Preventing Suicidal Behavior • General Staff Procedures • Risk Assessment and Referral Protocol • Suicide Postvention

45. Risk Assessment and Referral Protocol • Whenever a student judged to have some risk of engaging in self-directed violence or suicide, a school-based mental health professional should conduct a risk assessment and make the appropriate referrals.

46. Risk Assessment and Referral Protocol • Identify suicidal thoughts. • Conduct a risk assessment and make appropriate referrals. • Consult with fellow school staff members regarding the risk assessment and referral options. • Consult with County Mental Health regarding the risk assessment and referral options. • As indicated, consult with local law enforcement about referral options.

47. Risk Assessment and Referral Protocol • Use risk assessment information and consultation guidance to develop an action plan. Action plan options are as follows: A. Extreme Risk • If the student has the means of his or her threatened suicide at hand, and refuses to relinquish such then follow the Extreme Risk Procedures. B. Crisis Intervention Referral • If the student's risk of suicide is judged to be moderate to high, but means of violence are not at hand, then follow the Crisis Intervention Referral Procedures. C. Mental Health Referral • If the student's risk of suicide is judged to be low and means of violence are not at hand, then follow the Mental Health Referral Procedures.

48. Risk Assessment and Referral Protocol A. Extreme Risk • Have school administration call the police. • If it is judged safe to do so, attempt to calm the student by talking and reassuring him or her until the police arrive. • If it is judged safe to do so, continue to request that the student relinquish the means his or her threatened suicide and try to prevent the student from harming self or others. • Call the parents and inform them of the actions taken.

49. Risk Assessment and Referral Protocol B. Crisis Intervention Referral • Determine if the student's distress is the result of parent or caretaker abuse, neglect, or exploitation. • Meet with the student's parents or caregivers. • Determine what to do if the parents or caregivers are unable or unwilling to assist with the crisis. • Make appropriate referrals.

50. Risk Assessment and Referral Protocol C. Mental Health Referral • Determine if the student's distress is the result of parent or caretaker abuse, neglect, or exploitation. • Meet with the student's parents or caregivers. • Make appropriate referrals. • Protect the privacy of the student and family. • Follow-up with the referral resources (e.g., hospital or clinic).